Abstract
BackgroundThe formation of bile duct bezoars is a rare event. Its occurrence when there is no history of choledochoenteric anastomosis or duodenal diverticulum constitutes an extremely scarce finding.Case presentationWe present a case of obstructive jaundice, caused by the concretion of enteric material (bezoars) in the common bile duct following choledochoduodenal fistula development. Six years after cholecystectomy, a 60-year-old female presented with abdominal pain and jaundice. Endoscopic retrograde cholangiopancreatography demonstrated multiple filling defects in her biliary tract. The size of the obstructing objects necessitated surgical retrieval of the stones. A histological assessment of the objects revealed fibrinoid materials with some cellular debris. Post-operative T-tube cholangiography (9 days after the operation) illustrated an open bile duct without any filling defects. Surprisingly, a relatively long choledochoduodenal fistula was detected. The fistula formation was assumed to have led to the development of the bile duct bezoar.ConclusionBezoar formation within the bile duct should be taken into consideration as a differential diagnosis, which can alter treatment modalities from surgery to less invasive methods such as more intra-ERCP efforts. Suspicions of the presence of bezoars are strengthened by the detection of a biliary enteric fistula through endoscopic retrograde cholangiopancreatography. Furthermore, patients at a higher risk of fistula formation should undergo a thorough ERCP in case there is a biliodigestive fistula having developed spontaneously.
Highlights
The formation of bile duct bezoars is a rare event
Bezoar formation within the bile duct should be taken into consideration as a differential diagnosis, which can alter treatment modalities from surgery to less invasive methods such as more intra-endoscopic retrograde cholangiopancreatography (ERCP) efforts
Suspicions of the presence of bezoars are strengthened by the detection of a biliary enteric fistula through endoscopic retrograde cholangiopancreatography
Summary
Induced by intra-enteric materials transmitted through long fistulae, bezoar formation should be considered as an extremely rare differential diagnosis for obstructive jaundice since it is not normally associated with such relatively common predisposing factors as choledochoenteric anastomosis or duodenal diverticulum The ability of ERCP in detecting fistulae in a case of obstructive jaundice helps less invasive measures (more intra-ERCP views and efforts) outweigh surgery. When the macroscopic characteristics of the stones resemble those of bezoar material, it is expedient that surgeons allocate more time and effort to detecting and ligating the possible fistula. We hope that this case report of fistula formation with subsequent bezoar production and obstructive jaundice will raise the awareness of gastroenterologists and surgeons about such an interesting phenomenon
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